Personality disorders describe enduring, pervasive, pathologic patterns of behavior and inner experiences that deviate from a patient’s culture. Personality disorders are divided into three clusters depending on core features. Diagnosis of a personality disorder is generally made based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, although other diagnostic modalities exist. The most common disorders in primary care settings include obsessive-compulsive personality, narcissistic personality, and borderline personality disorders. Obsessive-compulsive personality disorder is associated with pathologic perfectionism and intense rigidity. Treatment is primarily psychotherapy, although there is some evidence for using selective serotonin reuptake inhibitors. Narcissistic personality disorder is marked by grandiosity, need for admiration, and a lack of empathy. Psychotherapy is the primary treatment. Borderline personality disorder is associated with instability and intense reactivity, and the primary treatment is typically psychotherapy. Dialectical behavior therapy was developed specifically for borderline personality disorder, although evidence suggests other behavior therapies may be as beneficial.
Case 3. AR, a 29-year-old, comes to your office with her boyfriend to discuss mood instability. She reports feeling manic and depressed, which she says can occur multiple times a day. She also says that sometimes things do not seem real to her, and it feels like she is just an empty shell. Her boyfriend says she is a kind and loving person but can suddenly be impulsive and paranoid. She recently became angry with him when he did not propose to her while on a dinner date and cut herself on the wrists repeatedly with a steak knife.
Definitions
The Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revision (DSM-5–TR), describes personality disorders as an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the patient’s culture, is pervasive and inflexible, has onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.1
Personality disorders are categorized into three clusters, each highlighting a common feature. Cluster A encompasses paranoid, schizoid, and schizotypal personality disorders. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. Avoidant, dependent, and obsessive-compulsive personality disorders belong to Cluster C. Approximately 9% to 15% of adults in the United States have at least one personality disorder.1,2
Most guidelines for the care of patients with personality disorders focus on three areas: diagnosis based on a structured clinical assessment, abstaining from use of pharmacologic treatment, and use of evidence-based psychological therapies.3
Diagnostic Approach
A lack of consistent and high-quality evidence hinders the development of strong clinical practice guidelines for the diagnosis and treatment of personality disorders.3 The diagnostic criterion for each disorder is specific to that disorder. However, there are two common diagnostic approaches that clinicians can use: categorical and dimensional. The categorical approach, which is used in the DSM-5–TR, is the more common choice.4 This approach centers on diagnosis based on reported symptoms organized by category.
The International Classification of Diseases, 11th ed., and the DSM-5–TR Alternative Model of Personality Disorders (AMPD) address the diagnosis of personality disorders dimensionally.4 The dimensional approach focuses primarily on personality functioning and pathologic personality traits.4 For the DSM-5–TR AMPD, this is accomplished through a set of criteria labeled A through G that can be applied across different personality disorders.
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